LIFE INSURANCEGENERAL INFORMATION Date Client Name DOB Height Weight Tobacco/Nicotine User? YesNo Current user? YesNo Frequency: Type used: cigarettescigars, pipechewnicotine patchnicotine gumhookaelectronic cigarettemarijuanaother Quit (date usage stopped): Any history of drug or alcohol abuse or treatment? YesNo Has any parent(s) or siblings(s) been diagnosed with, or died from, heart disease, diabetes complications or cancer? YesNo Who? If yes, from which condition? Age Diagnosed: Age Died: Do You Have High Blood Pressure? YesNo Current BP reading: Cholesterol: Any conditions related to the heart? (angioplasty, bypass, heart attack, etc.) AngioplastyBypassHeart AttackOpen Heart SurgeryOtherNo Any cancer in the past 20 years? —Please choose an option—YesNo Any surgeries in the past 20 years? —Please choose an option—YesNo Any history of diabetes? YesNo Age Diagnosed A1C: Name all medications currently or previously taken including dosage, reason prescribed and how long have you been taking them? Compliant on taking and is the condition controlled? YesNo Any other medical impairments or underwriting concerns? YesNo More than one moving violation in the last 3 years? YesNo DUI, Reckless Driving or suspension of driver’s license in the past 10 years? YesNo Ever convicted of a misdemeanor or felony? YesNo -+ Are you a U.S. Citizen, permanent resident or green card holder? YesNo Do you fly in an airplane or participate in other hazardous activities (SCUBA diving, mountain climbing, diving, racing, etc.)? YesNo Active military? YesNo Branch Rank Deployment(s) - When? Where? How long? Product desired, including face amount and premium range: ContinueREQUEST A QUOTE How did you hear about us?* —Please choose an option—Tom Martino's Troubleshooter ShowRefealist.comGoogleI have worked with Compass beforeSocial MediaWord Of Mouth —Please choose an option—FacebookInstagramLinkedInTik TokYouTube First Name* Last Name* Email Address* Phone Number* Home*Mobile* Address* Apt# City* State* Zip* Aside from price, what are your biggest priorities when it comes to your insurance?* —Please choose an option—Superior Customer ServiceFinancial StabilityConvenient Billing OptionsSuperior Claims ServiceOnline Services BUNDLE AND SAVE QUOTE Auto + HomeAuto + CondoAuto + Renters Please select all insurance products you would like us to quote for you.* AutoMotorcycleHomeownersCondoRentersWedding & EventLifeRV & TrailerWatercraftFloodUmbrella Do you consent to receiving text messages from our office regarding your application or policy?* (Carrier data rates may apply) YesNo Submit Upload Your Declarations Previous
